Last saved by: Rita Wilson

Gold Star Information Form
Due to County Office - June 12, 2017
Please complete using information based on 2016-2017 school year.
County: | Age as of September 2016:
Name: | Grade in School:
Address: | Phone Number:
City, State, Zip:
Number of years in 4-H: | Email Address:
Name of High School:
Parents Names:
4-H Club Name:
Recordbook Category Entry:

List 4-H Projects Involved in:
1. | 5.
2. | 6.
3. | 7.
4. | 8.
Leadership Positions You Have Held (Club, County, District, State)
1. | 5.
2. | 6.
3. | 7.
4. | 8.
Committees You Have Served on  (Club, County, District, State):
1. | 3.
2. | 4.
Community Service Projects (Club, County, District, State):
1. | 5.
2. | 6.
3. | 7.
4. | 8.
Awards Received:
1. | 3.
2. | 4.
Continued on back:
Please write a short narrative about what 4-H has meant to you and why you desire to be a Gold Star Recipient.